Provider Demographics
NPI:1851648323
Name:WALLS, LYNN SANDFORD VICTORIA (ANP-BC)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:SANDFORD VICTORIA
Last Name:WALLS
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:481 AARONS WAY
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48462-9046
Mailing Address - Country:US
Mailing Address - Phone:248-660-6497
Mailing Address - Fax:
Practice Address - Street 1:481 AARONS WAY
Practice Address - Street 2:
Practice Address - City:ORTONVILLE
Practice Address - State:MI
Practice Address - Zip Code:48462-9046
Practice Address - Country:US
Practice Address - Phone:248-660-6497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704257292363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health